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PERMIITEE NAME/ADDRESS (Include Facility %ume'l urmvui if Pyprent <br />NAME <br />ADDRESS <br />FACILITY <br />LOCATION <br /> <br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES) <br />DISCHARGE MONITORING REPORT (OMR) <br />I I <br />PERMIT NUMBER DISCHARGE NUMBER <br />MONITORING PERIOD <br />FROM YEAR MO DAY TO YEAR MO DAY <br />rt <br />f <br />Form Approved. <br />OMB No, 2040-0004 <br />ul.flVN I +C'!'-' I <br />NOTE: Read Instructions before completing this form. <br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION NO. FREOUENCY SAMPLE <br /> OF <br /> EX ANALYSIS TYPE <br /> AVERAGE MAXIMUM UNITS MINIMUM AVERAGE MAXIMUM UNITS <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT !. <br />- - - <br /> PERMIT _ <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> PERMIT <br /> REQUIREMENT y l•; ., <br /> SAMPLE <br /> MEASUREMENT - <br /> PERMIT <br /> REQUIREMENT <br /> SAMPLE <br /> MEASUREMENT <br /> <br /> PERMIT <br /> REQUIREMENT _, ,;?;;'.. ,<, • _ <br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 eertih under prnally of law that this dowvment and all attachment% were <br />ar <br />ti <br />d <br />d <br />di <br />i <br />i <br />i <br />d <br />i <br />h TELEPHONE DATE <br /> prep <br />e <br />un <br />er mi <br />rec <br />on or superv <br />n accar <br />s <br />on <br />ancr w <br />a .-tent designed <br />t <br /> t„ assure that qualified lies nnel properh gather and esaluate 11. information <br />submitted. Hared on my inquire of the pr- or persons who manage the system <br /> . <br /> or thane pe-mi, directh responsible for gathering we information, the (nfornwtion <br /> submitted is. to the lwat of my knowledge and belief. true, accurate. and complete. <br />I am aware that there are significant <br />wnaltu, for whmitting falst• inform <br />tio SIGNATURE OF PRINCIPAL EXECUTIVE <br /> <br />TYPED OR PRINTED I <br />a <br />n. <br />including the pnsihilih of fine and impru wtmrm for knowing eioluuons. <br />OFFICER OR AUTHORIZED AGENT <br />AREA CODENUMBER <br />YEAR <br />MO <br />DAY <br />AND EXPLANATION OF ANY VIOLATIONS (Reference all attachments here) <br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. This is a 4-part form.